Mental Health is an Uncomfortable Subject

Mental Health is an Uncomfortable Subject

Mental Health is an uncomfortable subject for many, it calls on us to face our vulnerability, consider our attitudes, and possibly reconsider our bias. Just because we work in healthcare, don’t think we have this covered.

In my years in emergency care, I’ve seen the whole range of emotion, behaviour and deflection play out when it comes to mental health – from denying it’s a ‘thing’ to real love and compassion. I’ve seen lives shattered and beautiful reconnections. 

On a more personal note, I know first-hand how devastating, isolating and all-consuming poor mental health can be. On the cusp of adulthood, I suffered a period of extreme anxiety, agoraphobia, panic attacks, the works – it derailed my life completely. 

I felt weak, less than my peers, ashamed, inadequate and afraid – for many years after I had recovered from the acute bout. I never talked about it, even within my own family. I went through college, my nursing career, my friendships and early relationships terrified anyone would find out – in doing this I helped maintain the stigma. 

In fact, it was one of the most powerful periods of my life, it has totally shaped the human I have become. Yet it has taken me decades to feel able to talk about it – to acknowledge that I, like at least 30% of the population, have suffered poor mental health.

This is why awareness weeks are important. It is not about a hat tip to mental health, it’s about healing – healing the attitudes, the stigma, the judgement even. It’s about making what can sometimes be invisible, visible. It’s about how we stay connected to ourselves and our fellow humans – how we really lean into the discomfort of facing stuff we might not be able to fix.

In healthcare we have two responsibilities here – the way we care for our patients and the attitudes we bring, and perhaps even more critically the way we care for each other and the judgements we make. There is no doubt that this last year made an assault on the mental health of most across the healthcare world at some point or another. 

Denying this or pushing it down is not the answer: creating time and space to deal with it is. Some of the principles outlined in Mental Health Awareness week are about connecting with nature – even for a few minutes, they help to ground, connect and energise us for sure. Check out The Mental Health Foundation focus on nature this week, you can check out their aims and evidence here

While focussing on what you can do to restore yourself is important, it can be undone in a second by judgement, invalidation and organisational culture.

As well as the practical mental health strategies offered during mental health awareness week, let’s consider the bigger picture here. Let’s start to heal the rift, the othering, the disconnection that our attitudes and beliefs around mental health have created – and by default what people who experience poor mental health endure.

This starts with each of us getting brave enough to look inward at our own views, biases and experiences, then look at what we put out into the world and consider what impact that has. Then the tougher bit, consider whether this is who we want to be or whether we might have some things to reconcile. 

Try this short exercise:

  • Sit somewhere comfortable where you won’t be disturbed for 5 -10 minutes. You might want a pad & pen to capture your learning, if you journal you may want to allow a little extra time at the end to free write, and you may prefer just to be in the moment, there is no right or wrong here.
  • Take a few slow deep breaths to centre yourself
  • Now ask yourself what you believe, no judgement – just feel it. Take note of the emotion that comes up, not just the words. How do you feel?
  • Then consider where it comes from – is it experience, is it fear, is it inherited, is it true? 
  • Is this how you want to show up in the world?
  • Keep focused on your emotion, what you are feeling, – is there something, someone, or maybe even yourself, you need to forgive, is there anything you need to let go of in order to show up how you want to? Do this now, feel the emotion and let it go.
  • What have you learned?

This is the simplest form of healing conversation. Neurologically if we don’t experience our emotions, we can’t fully process what happens to us, our experiences or memories get misfiled or supressed, and our beliefs and attitudes get distorted. Denial, judgement and othering are all examples of this distortion. 

Healing conversations enable us to reconnect with what we feel and reprocess and potentially reconcile what we think and how we show up – allowing us to connect more around the things that are important to us. 

All healing starts within, hence the conversation with yourself first. As humans we also have a lot of collective healing to do, there are so many global, cultural, national and local issues and none of us can champion everything. I fundamentally believe that connection and contribution are ingredients for good mental wellbeing, so think about what is important to you, what you have control and influence over and start to explore how you can contribute to healing. 

For me, one of these things is mental health awareness – rewriting the narrative, reducing fear – and ignorance, acknowledging the progress being made and the journey we still have to go on. In healthcare we need to be mindful of our narrative, our organisational assumptions around resilience and mental toughness and remember that compassion and kindness often have much greater impact.

Poor mental health is debilitating enough, without social stigma, judgement or even well-intentioned avoidance, so this week focus on what you can do. You don’t have to fix stuff, or say the right thing. You just have to show up – this might be a kind word, a connecting smile (masks permitting), or checking in on a friend. 

A little thing for you might mean the world to someone else.

Coming back to Mental Health Awareness Week and nature.

All nature, and particularly the sea, is very grounding for me so I’m treating myself to a few days working from the seaside this week, enjoying this force of nature, the picture above doesn’t do it credit! Sea air has evidenced benefit for your neurological wellbeing, it is charged with negative ions, increases oxygen uptake and serotonin production. 

Until next time look after yourself and those around you and #ConnectWithNature

With love 


The Power of Story – Part 2

The Power of Story – Part 2

The Power of Story – Part 2 – Your Internal Stories Are Your Lived Reality.

Every feel like you are stuck in ground hog day? You do the same stuff over and over, run up against the same obstacles, probably have the same disagreements with people you care about, not only that you’ve been there so many times you can probably predict the way those around you are going to react and behave also. There’s good reason for you to feel this way.

Your brain is a very clever piece of kit – until it’s not. It has a sophisticated neural network as we discussed in part one of this series, the trouble is it doesn’t differentiate between real and imagined. Which basically means whatever you are thinking about, focused on or actually doing has the same amount of power over how you feel, how you show up and what you actually achieve. Great news if you are feeding your brain with empowering, self-affirming stories – the trouble is most of us do just the opposite.

We are wired to stay safe, to repeat patterns and to fear the unknown, therefore most of your unconscious narrative serves exactly that purpose. Unconscious is the key bit here, you repeat the stories, or patterns so frequently they are just part of who you are – you probably don’t even recognise them as stories – they are just part of who you are.

How you see yourself is totally tied up in the stories you tell yourself! Unless you can identify these stories and manage them, they will continue to drive your life – and you will probably think it is just fate.

Over many years of working in healthcare I’ve talked to 1000’s of people defined by their stories, people from all backgrounds, people making a real difference to patients and carers, people who have stories of lack – not being senior enough, not having enough time, not being bright enough, not being listened to, not being allowed  and so on. All of these stories keep you stuck, they create self-limiting beliefs, things you can’t do or won’t achieve – mostly because you don’t believe it is possible.

If you are feeling irritated reading this, if you are thinking  it’s not me – it’s an over pressured health system, then take a breath, there is always something you can do, you always have some control – even if it is only over yourself and how you engage. To identify what stories are driving you start with your favourite excuses or ‘inner critic’ – both of which serve to stop you taking risks that might impact on your ‘safety’.

Many self-limiting beliefs grow from stories created in moments of emotional processing. Daniel Goleman (1995) calls this Emotional Hijacking – essentially something happens and your limbic system, particularly your Amygdala reacts to the stimulus more quickly than your more logical neocortex can think and plan its response. The limbic system fills in the gaps between actual knowledge and a coherent story, drawing on previous emotional encounters creating a physiological reaction often reinforcing your existing values and beliefs. And so the hijacking cycle is created.

Your story might have created the problem in the first place, but it is also a fast and sustainable route to behaviour change. You have control over what you choose to believe, you have some choice about the story you tell yourself – when you pay attention.  It the story you are repeatedly telling yourself doesn’t serve you choose a different one. Here’s how.

Step one:

Get familiar with your stories,

  • What do you repeatedly tell yourself? (think inner critic here if you are struggling)
  • What do you really believe about yourself? Good and bad.
  • What excuses do you consistently make?

Once you bring these into your consciousness you can start to unpick them. I find Robert Dilts’s Neurological levels model helpful here.

Let’s start from the bottom, Environment represents where and when, Behaviour is what you do, Skills represent how you do it, Values and beliefs why, and identity is who you are (or how you see yourself). Spirit then represents you vision /purpose.

When looking to make a change in your story (or your beliefs), you need to work at a level above where the problem exists – so for the most part this is at identity level – most challenges come from what you believe to be true about yourself (or your internal stories). 

Having identified your stories step two is deciding whether or not they are helpful and empowering or whether they limit you.

I suggest you dump down all the stories you tell yourself regularly then ask the following questions:

  1. Is it true?
  2. Does it serve me?

Some stories when you look at this way are clearly not true – your logical brain can see that straight off, these you need to deal with. Despite this your brain will seek to prove you right, it will look for evidence to support whatever you are focused on. The best way to deal with them is to consciously focus on the evidence that proves your limiting belief is untrue.

For example:

I can’t change the system – at a macro level this might be true, but within your immediate environment it is most definitely not true. If you focus on change you have made, or are making everyday, you will find plenty. It might be the small stuff, things that seem ordinary to you that makes the biggest difference. These might be things that you choose to do in the moment that make a real difference for those you are caring for, or it might be the way you are with those you work with changing the focus from what you can’t do to what you can or have done. The key here is focus. Whatever you focus on, your brain will start to look for more evidence and gradually replace the ‘I can’t story’ with a new one.

Some beliefs you hold may actually be true but believing them may not serve you. Here you are in the game of possibility – is it possible. I was lucky enough to work in emergency care in the early days of advanced trauma care courses – yes, I am that old!! At that time nurses didn’t run trauma calls, or resus’s for that matter so to expect that I could do that was untrue, but it was possible – from possibility came probability which became reality – because instead of owning the ‘nurses can’t do that’ I (along with some equally forward thinking colleagues) believed it to be possible, found plenty of evidence supporting it and in my small corner of the world got suitably qualified nurses running traumas.

Finally, the best way to deconstruct stories that are not true, or don’t serve you, is to decide what you need to believe to achieve what you want to achieve or be the person you want to be.  The trick here is to make the new story a stretch but believable, I might get nurses running trauma calls but not cracking open chests in ED!

Once you identify what you need to believe creating the right story to support it becomes easy. Your message is what drives you, create compelling stories around why you are sharing it, what you have done so far and where you have evidence of succeeding previously – then start to take some action, this sends messages to your limbic system that undo the emotional hijacking you may have previously created. A new story forms.  

In short, you choose what you believe either consciously, in a focused empowering way, or unconsciously by default based on your past experiences and beliefs – either way story is the answer. Do yourself a favour and create stories that help you be the best version of yourself

The Power of Story – Part 1

The Power of Story – Part 1

The Power of Story – Part 1 – How your brain creates story

Collective story is the basis on which cultures are built – ancient or modern. Your collective stories determine the environment your work in. The way we tell story and consume story has changed throughout history in line with the technology available – the way we process it has not!

Storytelling seems to have been around for as long as we have. Cavemen used story in the form of drawing and signs on rocks to share tales and teach about hunting, ancient Egyptians used story to educate, entertain and communicate – both visually and audibly, antient Greek philosophers – such as Plato, told stories that still impact the world today. They understood the power of story, even if they didn’t understand the neurological workings of why story is important.

“ Those who tell stories rule the world ”.

Plato (about 2400 years ago)

Story helps us to make sense of the world around us, it helps us to connect, to understand and to see perspectives other than our own. We can dip into a make-believe fantasy world for while, explore other realities and immerse ourselves in things it may not be practical to experience in ‘real life’. 

Coherence is far more important than accuracy when processing information. Your brain is attempting to sort and react to billions of pieces of information from internal neuro pathways and external stimuli every second. It has to prioritise what might create a threat to your safety and deal with that first.  

Think about it like this – if your brain were a rail system the objective is to get trains from start to destination as quickly and safely as possible. Information fed to the ‘controller’ forms the basis of decision making – does the train go straight through, does it need to change line, does it need to stop completely? The sooner the controller can process that information the sooner he can move on to the next train. If the controller can see the whole rail circuit, what else is on the line, what the weather is like etc, then he can make a rapid decision, if he can only see part of the picture he cannot. This slows the progress of all trains.

Your brain uses narrative to process information quickly – that narrative is derived from memories, experiences and neurological conditioning. There are a number of different parts of the brain involved in memory formation, the key ones in terms of narrative are:-

The hippocampus, which stores linear and autobiographical information, time, space and people.

The amygdala attaches emotional significance to memory. This emotional significance is critical in how we process information – strong emotional responses such as shame, guilt, grief, and fear can create a physiological trigger when faced with similar information in the future.

The amygdala is also key to forming new memories – particularly those related to fear or threat to safety. When information is incomplete the brain processes what it has drawing on narrative from your memory to ‘join the dots’ create the appropriate physiological response.

The neocortex is responsible for higher functions and processing in humans – it stores ‘facts’, language and reasoning, the challenge is that overtime we transfer ‘memories’ from the hippocampus to the neocortex as facts – whether they actually happened the way we recall them or not.

Why does this matter? From a very early age we tell ourselves stories about our actions, our experiences and the responses and actions of others, these stories create a reality within which we exist – this can either expand our perspectives and horizons or constrain them depending on the types of story we tell ourselves.

Ultimately, story – whether internally or externally created, enables us to relate, to connect and to engage emotionally. It drives our behaviour, our feelings and the action we take. Consciously or not we all use story to process information and the quality of your stories has a direct impact on the quality of your life.

Most of this story creation happens at an unconsciously – we might be aware of the trigger incident, but not the story and neurochemical reaction attached to it. Until you start to pay attention to your stories they will be the silent controller of your destiny.

Part two of this storytelling series helps you to unpick your stories.

Are You Part Of The Problem

Are You Part Of The Problem

I have the great privilege of working with multiple healthcare providers across different sectors in different parts of the globe – one thing is common to all; great people rock up every day to do difficult work in often challenging circumstances.

The stakes are high in health aren’t they? It’s people’s wellbeing, if not their lives we are trading in, and with this is mind the quest for continuous improvement in the service we offer and the way we offer it is reasonable. What is not always reasonable is the way we go about improvement and change. It is not reasonable to keep expecting the same people to do more and more, while under more scrutiny and with no more resource. All that this does is turns great people into, at best, tired people and, at worst, stressed out burnout people.

I believe continuous improvement is desirable and doable, if – and it’s a big if – we are prepared to take a different approach. Healthcare is, in the end, about patients, about delivering a good and effective care that enables patients to have the best life possible. The things that make a difference to patients are often the small human touches, the feeling like they matter in a big faceless system, the feeling they are safe and someone is watching out for them. This is not dissimilar to why people in healthcare come to work.

Throughout my career I have been lucky enough to witness ordinary people making extraordinary differences to patients over and over. Sometimes this gets recognised and sometimes it does not. I’m not for a second against standards and targets in healthcare – in fact I think they are essential. They define what good looks like. I am, however, completely opposed to the gaming, lip service and manipulation that goes on around such measures, as well as the pressure staff at all organisational levels feel as they get torn between what they might see as best care and the demands of the target. This does not create change for the benefit of patients, this creates knee jerk reactions and at best sticking plaster change.

So how do we fix it? I think first we have to understand how we as humans tick, how our brain’s work. We don’t make decisions, or create change, even have conversations with people based on logic, rational thought and evidence base – much as we might like to think we do! We make decisions based on our emotions, drawn from beliefs, experiences and expectations. These of course are context driven, where we find ourselves, whether we feel safe, how much authority we believe we have, how much trouble we might get into, balanced with how much the issue in question matters to us.

Armed with this, it is not difficult to see why top down, often target based change initiatives don’t always thrive, and why our health care staff often feel pressured and undervalued. It also shows us that if change needs to be made, ownership of the reasons and outcomes of change are key to its success. I’m constantly wowed by the great ideas people have, even in the most challenged of health organisations – I’m also equally as disappointed by how little of a voice they often feel they have.

Even the best can still improve, make the improvement conversation positive, values driven and based on the emotional drivers that actually matter to your team. Listen and come up with solutions together. Then create a road map for change that has the following four attributes:

  1. It is easy to follow  – it is easy to implement in their day job
  2. It is attractive – they buy into the outcome and it delivers some benefit for them, whether directly or indirectly
  3. It is social – there is some element of competition, gaming or social currency attached ( this might even be social media)
  4. It is timely – there is a need for the change now and an opportunity to make a difference now

(based on Behavioural Insights Team 2010)

#EndPJparalysis is a good example of this. There were plenty of ideas and resources available to make implementation easy, the concept was value led and attractive to people, it was social, the campaign ran on twitter and in a closed facebook group enabling people to share their successes and challenges, and it was timely – there were a specific 70 days for the challenge. The momentum is maintained through ongoing local activity, measuring of successes and a 3 day global online summit 10th-12thJuly.

Going back to how humans tick: belonging, security, autonomy (within boundaries), and significance are among the things considered important to how we engage. A few small changes in how we talk to each other and how we value each other’s contributions at work could make a big impact on how and whether change happens. People engage and contribute when something matters to them. So have conversations about value, about impact, about doing the right thing, not about waiting times, lists and failures. 

If we can start to address these in the workplace we can rapidly make it safer for people to speak up, to make change in their area and genuinely contribute to continuous improvement in healthcare. Then we are part of the solution and not the problem.

Wilful neglect ?

Wilful neglect ?

Wilful neglect – is ignoring it collusion?

Pilots who consume alcohol and potentially endanger their passengers, or farmers who deliberately breach food hygiene regulations, like many other professionals face are severe penalties that include loss of license and livelihood, and even potential imprisonment. Should nurses or doctors be any different?

The response to the Government’s plans to criminalise wilful neglect, including in some cases with prison sentences, have been met with predictable outrage by the medical and nursing colleges, who have called it a ‘headline-grabbing exercise’ (BMA). That may have been the press’ agenda, but is it really unreasonable for the Government to hold to account those engaging in wilful neglect?

Making wilful neglect a criminal offence was just one of a number of recommendations made by Don Berwick in his review of the Mid Staffordshire Hospital Inquiry. Berwick’s report also stressed that there are very few examples of wilful neglect in the NHS and (perhaps ironically), called for an end to the ‘blame game’ against NHS staff.

To say nurses and doctors will live in fear of prosecution is scare mongering. Mid staffs happened because of multiple system failures, not because of particular individuals, that was not wilful neglect on the part of clinicians – but individuals allowed disgusting circumstances to prevail. It took relatives and statistics to expose the problem. The fact the staff did not speak out is indicative of a wider cultural issue.

wilful neglect

Structural deficits such as staffing levels and quality, budget constraints, poor leadership and work environments collude to leave NHS staff feeling ‘got at’ by health ministers, the press and often by their local organisation leaders too;  many of whom appear to criticize the NHS far more frequently than they praise it.

Berwick, in this and many other reports he has authored, is consistently right about culture; and we do need to change the culture in some NHS organisations. We also need to create environments where clinicians to feel safe enough to say ‘No, this is not right’.  There also needs to be a route to expose and deal with individuals and systems that wilfully neglect patients – whether clinicians or not!

Critics have expressed concern that it will further reinforce a climate of fear, and unless clarification about what constitutes ‘wilful neglect’ by an individual or group of individuals is made explicit this may be the case. This should not, however be used as an excuse for not taking action. Instead of creating a perceived need to fear accountability for wilful actions, perhaps leaders and influencers should  focus on what sits outside of acceptable practice. This will enable the vast majority of clinicians who do a good job, often despite difficult circumstances, to concentrate on patients and care delivery.

There are also places where honesty, transparency and willingness to deal with difficult behaviours and unacceptable practices prevail. They focus on willful improvement to prevent willful neglect ever happening.

Instead of getting caught up in the hype of potential prosecution, perhaps the question we should ask is ‘how do we identify and root out the few in our professions who are prepared to engage in wilful neglect’?